I know it's expensive but isn't insurance to provide medication for illness? I don't understand being denied a medication like Pulmozyme that is the only one of it's kind that can break up dna in the lungs for cf. I was shocked when I heard that it cost about $1700.00 per month. WOW! Anyone have ideas on how to get around this one? <img src="i/expressions/face-icon-small-disgusted.gif" border="0">
You are using an out of date browser. It may not display this or other websites correctly.
You should upgrade or use an alternative browser.
You should upgrade or use an alternative browser.
Denied Pulmozyme
- Thread starter grsswspr
- Start date
I know it's expensive but isn't insurance to provide medication for illness? I don't understand being denied a medication like Pulmozyme that is the only one of it's kind that can break up dna in the lungs for cf. I was shocked when I heard that it cost about $1700.00 per month. WOW! Anyone have ideas on how to get around this one? <img src="i/expressions/face-icon-small-disgusted.gif" border="0">
I know it's expensive but isn't insurance to provide medication for illness? I don't understand being denied a medication like Pulmozyme that is the only one of it's kind that can break up dna in the lungs for cf. I was shocked when I heard that it cost about $1700.00 per month. WOW! Anyone have ideas on how to get around this one? <img src="i/expressions/face-icon-small-disgusted.gif" border="0">
Do you have a case worker (social worker) at your clinic? They are usually really good at finding a way to get the insurance to cover things. Yes, it is expensive, but so worth it! When I first started it, I stayed out of the hospital for 8 years! I think that ended up saving my insurance some $ in the long run <img src="i/expressions/face-icon-small-wink.gif" border="0"> . Usually insurance has an appeal process- again, the only person I know of to help is the cf clinic social worker, but maybe someone else knows something better. <img src="i/expressions/face-icon-small-wink.gif" border="0">
Do you have a case worker (social worker) at your clinic? They are usually really good at finding a way to get the insurance to cover things. Yes, it is expensive, but so worth it! When I first started it, I stayed out of the hospital for 8 years! I think that ended up saving my insurance some $ in the long run <img src="i/expressions/face-icon-small-wink.gif" border="0"> . Usually insurance has an appeal process- again, the only person I know of to help is the cf clinic social worker, but maybe someone else knows something better. <img src="i/expressions/face-icon-small-wink.gif" border="0">
Do you have a case worker (social worker) at your clinic? They are usually really good at finding a way to get the insurance to cover things. Yes, it is expensive, but so worth it! When I first started it, I stayed out of the hospital for 8 years! I think that ended up saving my insurance some $ in the long run <img src="i/expressions/face-icon-small-wink.gif" border="0"> . Usually insurance has an appeal process- again, the only person I know of to help is the cf clinic social worker, but maybe someone else knows something better. <img src="i/expressions/face-icon-small-wink.gif" border="0">
coltsfan715
New member
I have had issues in the past where my insurance will not cover some medications that I take. When that happens the pharmacist usually tells me and there is normally a phone number that the pharmacist can give me in those instances. The phone number is for the insurance company directly. What I then do is pass the number on to my doctors office and the docs office calls the insurance company and talks to the worker and normally it turns out that all they need to do is get a form faxed to the insurance (from the doc) saying what the med is for and that YES it is indeed medically necessary.
Normally having the docs office CALL gets the med covered. I have had issues with my docs writing letters - I have waited 6 months or more for some meds when my docs write letters and even with waiting 6 months the med is never covered cause the letters are never received. Due to that my docs offices always call now.
Did they give a reason for declining payment for the med. It may be as simple as preapproval or pre authorization for the med. That can be handled like I said above and I know with my insurance I could get my med the same day that my docs call.
Take Care and Good Luck,
Lindsey
Normally having the docs office CALL gets the med covered. I have had issues with my docs writing letters - I have waited 6 months or more for some meds when my docs write letters and even with waiting 6 months the med is never covered cause the letters are never received. Due to that my docs offices always call now.
Did they give a reason for declining payment for the med. It may be as simple as preapproval or pre authorization for the med. That can be handled like I said above and I know with my insurance I could get my med the same day that my docs call.
Take Care and Good Luck,
Lindsey
coltsfan715
New member
I have had issues in the past where my insurance will not cover some medications that I take. When that happens the pharmacist usually tells me and there is normally a phone number that the pharmacist can give me in those instances. The phone number is for the insurance company directly. What I then do is pass the number on to my doctors office and the docs office calls the insurance company and talks to the worker and normally it turns out that all they need to do is get a form faxed to the insurance (from the doc) saying what the med is for and that YES it is indeed medically necessary.
Normally having the docs office CALL gets the med covered. I have had issues with my docs writing letters - I have waited 6 months or more for some meds when my docs write letters and even with waiting 6 months the med is never covered cause the letters are never received. Due to that my docs offices always call now.
Did they give a reason for declining payment for the med. It may be as simple as preapproval or pre authorization for the med. That can be handled like I said above and I know with my insurance I could get my med the same day that my docs call.
Take Care and Good Luck,
Lindsey
Normally having the docs office CALL gets the med covered. I have had issues with my docs writing letters - I have waited 6 months or more for some meds when my docs write letters and even with waiting 6 months the med is never covered cause the letters are never received. Due to that my docs offices always call now.
Did they give a reason for declining payment for the med. It may be as simple as preapproval or pre authorization for the med. That can be handled like I said above and I know with my insurance I could get my med the same day that my docs call.
Take Care and Good Luck,
Lindsey
coltsfan715
New member
I have had issues in the past where my insurance will not cover some medications that I take. When that happens the pharmacist usually tells me and there is normally a phone number that the pharmacist can give me in those instances. The phone number is for the insurance company directly. What I then do is pass the number on to my doctors office and the docs office calls the insurance company and talks to the worker and normally it turns out that all they need to do is get a form faxed to the insurance (from the doc) saying what the med is for and that YES it is indeed medically necessary.
Normally having the docs office CALL gets the med covered. I have had issues with my docs writing letters - I have waited 6 months or more for some meds when my docs write letters and even with waiting 6 months the med is never covered cause the letters are never received. Due to that my docs offices always call now.
Did they give a reason for declining payment for the med. It may be as simple as preapproval or pre authorization for the med. That can be handled like I said above and I know with my insurance I could get my med the same day that my docs call.
Take Care and Good Luck,
Lindsey
Normally having the docs office CALL gets the med covered. I have had issues with my docs writing letters - I have waited 6 months or more for some meds when my docs write letters and even with waiting 6 months the med is never covered cause the letters are never received. Due to that my docs offices always call now.
Did they give a reason for declining payment for the med. It may be as simple as preapproval or pre authorization for the med. That can be handled like I said above and I know with my insurance I could get my med the same day that my docs call.
Take Care and Good Luck,
Lindsey
Dido what Lindsay said. I have had this issue with my insurance also. If the phone call from the Doc. doesn't work you might have to go through the appeals process to get the drug covered. While you are waiting, talk to your cf doc as they usually can find a way for you to get the meds you need on a temporary basis by getting drug companies to pay the cost. (many of the large pharmaceutical companies have programs to supply their drug to needy patients but they are only available through a doc and only on a short term basis) Good luck with the wonderful world of insurance!!!! Oh! I just remembered, in my area there is something called "children with special health care needs" that is run by the gov. If a person qualifies they offer medical coverage (and drug coverage) It is typically based on the family income level and the patient must have a qualifying health condition, which cf is. I don't know what they could do for you, but it never hurts to try. I am in Kentucky. If you want the phone number for ours here I can get it for you. Best of luck!!
Dido what Lindsay said. I have had this issue with my insurance also. If the phone call from the Doc. doesn't work you might have to go through the appeals process to get the drug covered. While you are waiting, talk to your cf doc as they usually can find a way for you to get the meds you need on a temporary basis by getting drug companies to pay the cost. (many of the large pharmaceutical companies have programs to supply their drug to needy patients but they are only available through a doc and only on a short term basis) Good luck with the wonderful world of insurance!!!! Oh! I just remembered, in my area there is something called "children with special health care needs" that is run by the gov. If a person qualifies they offer medical coverage (and drug coverage) It is typically based on the family income level and the patient must have a qualifying health condition, which cf is. I don't know what they could do for you, but it never hurts to try. I am in Kentucky. If you want the phone number for ours here I can get it for you. Best of luck!!
Dido what Lindsay said. I have had this issue with my insurance also. If the phone call from the Doc. doesn't work you might have to go through the appeals process to get the drug covered. While you are waiting, talk to your cf doc as they usually can find a way for you to get the meds you need on a temporary basis by getting drug companies to pay the cost. (many of the large pharmaceutical companies have programs to supply their drug to needy patients but they are only available through a doc and only on a short term basis) Good luck with the wonderful world of insurance!!!! Oh! I just remembered, in my area there is something called "children with special health care needs" that is run by the gov. If a person qualifies they offer medical coverage (and drug coverage) It is typically based on the family income level and the patient must have a qualifying health condition, which cf is. I don't know what they could do for you, but it never hurts to try. I am in Kentucky. If you want the phone number for ours here I can get it for you. Best of luck!!
M
mneville
Guest
We had also gotten denied for our two year old. The CF doc had to write a letter of medical necessity and appeal it. We then got covered but have to use a specialty pharmacy.
Megan
Megan
M
mneville
Guest
We had also gotten denied for our two year old. The CF doc had to write a letter of medical necessity and appeal it. We then got covered but have to use a specialty pharmacy.
Megan
Megan
M
mneville
Guest
We had also gotten denied for our two year old. The CF doc had to write a letter of medical necessity and appeal it. We then got covered but have to use a specialty pharmacy.
Megan
Megan
My son started pulmozyme about a month ago and the CF doctor/nurse filled out some paperwork from the manufacturer that gave us a free 30 day supply - apparently it is a standard thing from the manufacturer because they know alot of insurance companies give patients a runaround. I can't help you on your insurance company, but you should ask the clinic or maybe call the company about this free thing to at least get started.
My son started pulmozyme about a month ago and the CF doctor/nurse filled out some paperwork from the manufacturer that gave us a free 30 day supply - apparently it is a standard thing from the manufacturer because they know alot of insurance companies give patients a runaround. I can't help you on your insurance company, but you should ask the clinic or maybe call the company about this free thing to at least get started.